Friday we called in refills on a bunch of Casey’s medications. One of these was Prevacid. Casey has been on Prevacid pretty much since birth. This medication helps reduce her reflux. On Friday the pharmacy called to tell us that our insurance is no longer paying for this drug and that they wanted to know what we want to do. WHAT?! How does insurance just decide to no longer cover medications that are NEEDED? The pharmacy told us that it would be $300-$400 a month to fill this on our own.
I spent almost 2 hours on the phone with our insurance to find out they will not pay it. They suggested I file an appeal. I have done this with MANY items. This is never a smooth process. I have thousands of dollars spent out of pocket that we have been trying to appeal (some for over a year). I had enough pills to get us to Monday morning. I did not have a year or more to deal with the appeal process. They ended up joining their pharmacist on the call. I went on to explain that I can’t just give Casey a handful of Tums and send her on her way. With no swallow her reflux medication has to be in liquid form. That takes her options down to very few. Then add to that the fact that her reflux is severe and we need the strongest stuff we can get. That makes the list even shorter. Then add to that the fact that with her not being mobile I can’t maintain a weekly compound. I can’t guarantee that I can get to a pharmacy each week to pick it up. That pretty much closed out the list leaving just Prevacid. The pharmacist (our insurance’s in house pharmacist) agreed with me, Casey needs to be on Prevacid. Then when we added to this by pointing out reflux for Casey is not just spitting up, but that any spit up puts her at increased aspiration risk due to her lack of swallow.
Even though everyone on the call agreed that Casey should be given this exemption, no one could do it over the phone. It’s 2009, and the only way to file a drug appeal is by snail mail! That is so sad to me. Medical claims I can at least fax in, but for drugs they have to be mailed. The minimum to expect for this is 2-3 days in mail followed by 30 day turn around at the office. When I asked what our insurance offered as a plan B they didn’t have much to say. The listed out a few medications that Casey can’t take since they can not be liquefied, then went on to say they suggest I just purchase the medication and submit it for reimbursement after the appeal is approved. That is IF the appeal is approved.
I was really not happy with the answers I was getting so I got on the phone with Casey’s GI doctor/nurse to see what they suggest. When I called them I found out it is not just us. Most insurances have decided to no longer cover this class of medication. The doctor’s office was as frustrated as I was. They told me that the insurance companies are making it hard for them to treat their patients. The doctor did come up with a solution that luckily is covered by our insurance. When they called it the pharmacy was out of it. They did a special order and it came in early Monday. Just in time.
Yesterday Casey started running a low fever and just cried all morning. We got her some pain killers and she had a bath and her fever came down. She was just not a happy girl yesterday. She was so worked up that she would not take her afternoon nap. Around 5 she finally fell asleep. When she woke up at 6 we prepared for a long night. Surprisingly she went right back to sleep when we took her to bed around 8. We had to give her more medicine, but she was able to get comfortable and get a decent night’s sleep. She started out okay this morning but just before 10 she got all worked up again. Most of the morning has been spent suctioning non stop. She isn’t running a fever, but she is definitely not feeling well today. I hope what ever this is that’s bugging her passes soon. I hate it when she doesn’t feel good.
Her switch and supplies came in. We ended up getting the exact one that she had on loan from the school. It ended up being the cheapest, and since she was already used to it the transition was really easy. She is playing with it now. It seems to be one of the only ways to get her to calm down today.
That’s about it. Casey has a dentist and ENT appointment next week. All of her therapies start back up next week too. It will be a busy week around here. Congratulations to the Campos on the new baby. We hope everyone is enjoying spring break and doing well.